Double Balloon Enteroscopy Is a Safe and Effective Procedure in Removing Entrapped Foreign Objects in the Small Bowel for Up to 3 Months

Abstract

Recent case series have shown that enteroscopy is safe and effective to remove entrapped small bowel foreign bodies. However, the optimal timing for the foreign body retrieval in terms of duration of entrapment and when to consider surgical intervention are unknown. In this case series, we report that antegrade and retrograde enteroscopy can be used safely to retrieve foreign bodies entrapped in the small bowel for longer than 70 days. In total, 20 patients (mean age, 48 years; 11 females) with entrapped foreign bodies in the small intestine underwent antegrade, retrograde, or combined double balloon enteroscopy for retrieval of objects. Symptoms prompted removal of entrapped, nonsharp objects in all patients and included abdominal pain, nausea, and vomiting. The mean time of entrapment was 83 days (range, 4–272 days). There were 15 cases of retained video capsule endoscopy (VCE) with a mean entrapment time of 106 days (range, 7–272 days). Two VCEs could not be removed safely with enteroscopy. Other retained small bowel objects included in this study were nails and fish hooks. Their average entrapment time was 13 days (range, 4–43 days). Of the 30 enteroscopies, there was only 1 case (3%) with a complication (perforation). According to this case series, experienced endoscopists can safely and effectively retrieve foreign bodies in the small bowel, particularly VCE, that are retained for extended periods of time.

Introduction

Historically, entrapped small bowel foreign bodies were managed surgically if perforation, obstruction, or bleeding is evident. Alternatively, the literature recommends a conservative approach in asymptomatic patients.¹ Since the introduction of device-assisted enteroscopy, initially double balloon enteroscopy (DBE), evaluation of small bowel pathology encompasses routine gastroenterological practice. Recent case reports have widened the boundary of device-assisted enteroscopy for extraction of entrapped small bowel foreign bodies; however, the optimal setting for endoscopic approach remains yet to be defined, especially in the absence of consensus guidelines.² In particular, insufficient data exist for the safety and efficacy of the use of enteroscopy in patients with retained objects. Furthermore, for objects that remain in the small bowel that do not spontaneously pass through the digestive system, the duration that the entrapped object can remain safely in the small bowel is unknown. The aim of this study is to evaluate the safety and efficacy of DBE in the removal of entrapped small bowel foreign objects and to assess the duration that these objects can remain in the small bowel before intervention is necessary.

Patients and Methods

Patients

A retrospective study was performed based on a cohort of patients who underwent DBE from 2009 to 2014 at Mayo Clinic in Jacksonville, FL, for foreign body removal from the small intestine. At the time of the procedure, all patients were asymptomatic; however, all patients exhibited symptoms prior to the procedure that were attributed to the entrapped foreign bodies. These symptoms included a combination of abdominal pain with nausea and vomiting, suggestive of partial small bowel obstruction given their self-limited nature.

From electronic medical records, we obtained information such as patient demographics, procedure indications, procedure findings, endoscopic interventions, postprocedural recovery data, and hospitalization records. DBE procedure-related details such as DBE route, procedure time, diagnostic yield, and therapeutic intervention were also recorded. The study was approved by the Institutional Review Board of the Mayo Clinic.

DBE procedure

All DBEs were scheduled with an open access system in which the endoscopist performing the DBE screens the requests and approves procedure scheduling based on appropriateness of the procedure indication without having seen the patient. The decision of whether to perform the DBE through an oral and/or anal approach was dependent on the endoscopist's choice per the patient's clinical presentation and prior endoscopy and radiology findings. All DBEs were performed after appropriate informed consents were obtained. Immediately prior to the procedure, the endoscopist and the anesthesiologist obtained the clinical history and physical examination results. The decision of whether to proceed or to cancel the scheduled procedure was dependent on mutual agreement between the endoscopist and the anesthesiologist. DBE was performed by two trained, experienced gastroenterologists (M.E.S. and F.J.L.).

The EN450-T5 enteroscope (Fujinon Inc., Wayne, NJ) was used for all DBEs. It includes a 230-cm-long endoscope, an overtube, and a double-barostatic pump (PB-10 balloon pump controller) that allows controlled inflation of the endoscope and overtube balloons.

All DBEs were performed in a standard endoscopy unit with a portable fluoroscopy unit, and technicians assisting the process performed inflation–deflation of the balloons. Patients were required to have fasted for at least 6 hours prior to all endoscopy procedures. Sedation with general anesthesia or modified anesthesia care was used during all procedures. The elective placement of endotracheal intubation was dependent on the individual preference of the anesthesiologist and the endoscopist.

During the DBE, vital signs, oxygen saturation, and end-tidal CO₂ were monitored by the anesthesiology team. The endoscopist performed therapeutic procedures as necessary.

Outcome measures

Outcome measures were foreign body retrieval success rate, complication rate, and duration of entrapment.

Results

The mean age of patients was 48 years (range, 20–74 years); 11 patients were female. Fifteen patients (75%) had prior history of abdominal and/or pelvic surgery, of which 5 cases involved the small bowel. Four patients had small bowel Crohn's disease. Eight patients (40%) underwent a computed tomography scan prior to enteroscopy for localization of the foreign body (video capsule endoscopy [VCE], n=3; other ingested foreign body, n=5). There were 15 cases of retained VCE. Other retained objects included nails and fish hooks. The mean time of all foreign body entrapment was 83 days (range, 4–272 days). The mean entrapment time was 106 days (range, 7–272 days) for VCE and 13 days (range, 4–43 days) for sharp ingested objects. Symptomatic foreign body ingestion led to foreign body retrieval in 19 patients (95%). Signs and symptoms included abdominal pain and signs of bowel obstruction (nausea, vomiting); however, patients were asymptomatic at the time of the procedure. The 20 patients underwent a total of 6 antegrade, 4 retrograde, and 10 combined antegrade and retrograde enteroscopies for removal of objects. Nine cases required additional balloon dilation for retrieval of small bowel objects.

Foreign body extraction from the small bowel was successful in 17 cases (85%) using Roth net (76%), snare (11%), or forceps (11%). DBE additionally diagnosed 3 patients with small bowel Crohn's disease, 6 with nonsteroidal anti-inflammatory drug–inducing strictures, and 2 with anastomotic strictures. Of the 30 DBEs, 1 case (3%) was complicated by small bowel perforation following the successful removal of VCE at a Crohn's stricture requiring emergency surgical intervention. Information on patients, retained items, and procedures is listed in Table 1.

Table 1.

Characteristics of Patients

ID	Age (years)	Sex (F/M)	Foreign object	Days of entrapment	Symptoms	CT findings if available prior to retrieval	DBE (U/L/U+L)	DBE finding	Additional procedure	Successful retrieval
1	73	F	VCE	34	AP, N, V		U+L	NSAID stricture	Dilation	Yes
2	30	M	2 nails	4	AP	Nails in jejunum	U	No stricture or inflammation		Yes
3	37	F	VCE	142	AP		U+L	Crohn's stricture of distal jejunum with VCE		Yes
4	66	F	VCE	13	AP, N		U	NSAID stricture in mid-ileum	Dilation	No
5	57	F	VCE	270	AP, N, V		U+L	Crohn's stricture of ileum		Yes
6	55	M	VCE	12	AP, V		U	NSAID stricture of ileum	Dilation	Yes
7	36	F	VCE	180	AP		L	Crohn's stricture	Dilation	Yes
8	69	F	VCE	14	AP		U+L	NSAID strictures of distal jejunum		Yes
9	32	M	Nails	9	AP, N, V	Multiple nails in small bowel	U+L	Colocolonic anastomotic stricture		Yes
10	33	M	Fish hook	7	AP, N	Fish hook in small bowel	U	No stricture or inflammation	Dilation	Yes
11	33	M	Nail	4	None	Nails in small bowel	U+L	No stricture or inflammation		No
12	74	M	VCE	68	AP		U	Stricture in the mid-ileum	Dilation	Yes
13	69	F	VCE	210	AP, V	Retained VCE	U+L	Strictures in the jejunum	Dilation	Yes
14	74	M	VCE	136	N		L	NSAID strictures in mid-ileum		Yes
15	32	M	VCE	165	AP	Retained VCE	U+L	Crohn's stricture in terminal ileum		Yes
16	20	F	VCE	272	N		U	Crohn's stricture in distal ileum		Yes
17	30	F	Fish hook	43	AP, N, V	Metal object visualized	L	Stricture of the distal ileum	Dilation	Yes
18	46	F	VCE	7	AP, N, V	Partial small bowel obstruction; retained VCE at transition point	L	Stricture of the distal ileum		Yes
19	69	F	VCE	30	AP		U+L	NSAID stricture of the distal ileum		No
20	43	M	VCE	45	AP		U+L	Crohn's strictures in the distal ileum	Dilation	Yes

AP, abdominal pain; CT, computed tomography; DBE, double balloon enteroscopy; F, female; L, lower; M, male; N, nausea; NSAID, nonsteroidal anti-inflammatory drug; U, upper; V, vomiting; VCE, video capsule endoscopy.

Discussion

This case series demonstrates that entrapped small bowel foreign bodies can be removed endoscopically with a high success rate of 85% and a low complication rate of 3%, which is comparable with recently published data.³ This makes DBE a reasonable surgical-sparing option.

Our case series include mainly entrapped VCEs. The mean time of VCE entrapment was 106 days, with a range of 7–272 days, which is a longer safe time frame than previously reported in the literature.⁴ Symptomatic patients with entrapped small bowel objects are candidates for surgical resection according to current guidelines.¹ However, all underwent successful DBE in this study. Contrary to previously published data, we believe that asymptomatic VCEs do not require urgent removal as they can remain in the small bowel for more than 3 months without causing complications.⁵ Removal of objects from asymptomatic patients can be of benefit if tissue sampling of suspected stricture is required.⁶ Half of the strictures identified in this case series had an obvious etiology, including anastomosis and Crohn's disease, documented on the pathology report. Based on the history of nonsteroidal anti-inflammatory drug use and classic macroscopic findings, six strictures were attributed to nonsteroidal anti-inflammatory drug use. Two patients had small bowel strictures without an obvious etiology suggestive for chronic non-specific ulcer. Due to limited follow-up, cryptogenic multifocal ulcerous stenosing enteritis could not be excluded. We suspect that all identified strictures were already present at the time of VCE placement, resulting in their entrapment and not caused by prolonged foreign body entrapment. From our perspective, the indication for removal of a prolonged entrapped VCE is development of obstructive symptoms, including abdominal pain, nausea, or vomiting; however, the patient cannot be actively obstructed at the time of the procedure. Moreover, in this context, similar to upper gastrointestinal foreign body entrapment, exact guidelines do not exist.⁷

Our case series also included 5 patients with ingested sharp objects that remained entrapped in the small bowel for an average of 13 days. One patient was asymptomatic. All symptomatic patients underwent previous cross-sectional images to exclude perforation. Historically, these were patients with an indication for surgical exploration. In our series, all 5 patients underwent successful, surgical-sparing DBE. Retrieval of sharp objects did not cause complication necessitating surgical intervention.

In summary, VCEs can remain safely in the small bowel for more than 3 months in asymptomatic patients and can then be successfully removed with DBE if the patient becomes symptomatic. We also showed that entrapped, sharp small bowel objects, historically requiring surgical intervention, can be safely removed with DBE.

Footnotes

Disclosure Statement

No competing financial interests exist.

References

Ribas

, Ruiz-Luna

, Garrido

, Bargallo

, Campillo

. Ingested foreign bodies: Do we need a specific approach when treating inmates?. Am Surg, 2014; 80:131–137.

Jovanovic

, Vormbrock

, Zimmermann

, et al. Therapeutic double-balloon enteroscopy: A binational, three-center experience. Dig Dis, 2011; 29,(Suppl 1):27–31.

Makipour

, Modiri

, Ehrlich

, et al. Double balloon enteroscopy: Effective and minimally invasive method for removal of retained video capsules. Dig Endosc, 2014; 26:646–649.

Pennazio

, Santucci

, Rondonotti

, et al. Outcome of patients with obscure gastrointestinal bleeding after capsule endoscopy: Report of 100 consecutive cases. Gastroenterology, 2004; 126:643–653.

May

, Nachbar

, Ell

. Extraction of entrapped capsules from the small bowel by means of push-and-pull enteroscopy with the double-balloon technique. Endoscopy, 2005; 37:591–593.

Lee

, Choi

, et al. Retrieval of a retained capsule endoscope by double-balloon enteroscopy. Gastrointest Endosc, 2005; 62:463–465.

Ciriza

, Garcia

, Suarez

, et al. What predictive parameters best indicate the need for emergent gastrointestinal endoscopy after foreign body ingestion?. J Clin Gastroenterol, 2000; 31:23–28.